Low bone density often sneaks up on otherwise healthy women. It is generally asymptomatic until it’s too late and a fracture occurs! Fortunately, non-invasive screening with a DEXA test can identify osteopenia and osteoporosis early. When detected early, a number of strategies can be implemented to regain lost bone density, or at least prevent further deterioration.

The conventional approach to osteoporosis inolves the bisphosphonate medications and selective estrogen receptor modulators, and calcitonin. More recently, immunomodulator denosumab has become available. Whether women have had intolerable side effects from medications, or simply don’t want to take a drug, I often point them towards bioidentical hormone replacement therapy as an option to build bone density (in conjunction with supplementation to ensure the necessary vitamins and minerals are available to make new bone).

Bioidentical hormone replacement therapy, specifically estradiol, is an evidence-based approach that is supported by research and guidelines, despite getting less attention than the drugs. When women pass into menopause, and estrogen levels decline, we see a rapid rate of bone loss that is most dramatic over the first few years of menopause. Estradiol is known to prevent this bone loss and in fact has an FDA approval for the indication of osteoporosis prevention (but not treatment). According to a 2021 review of best practices for endocrinologists, “not only [does] MHT [menopausal hormone therapy] prevent bone loss and the degradation of the bone microarchitecture but it significantly reduces the risk of fracture at all bone sites by 20-40%. It is the only anti-osteoporotic therapy that has a proven efficacy regardless of basal level of risk, even in low-risk women for fracture.1 Thus, some countries, such as the UK guidelines, also include recommendations for the use of HRT for osteoporosis. 2

So, knowing that hormone replacement therapy is a proven strategy for maintaining or improving bone density, how do women know if it is right for them? And if so, what type of hormone replacement should they use?

The first consideration is to weigh the potential risks and benefits of both using hormones and the risks and benefits of not using them. As is usually the case, the answer is not one-size-fits-all; it depends on the individual. In terms of bone protection, estrogen replacement has been shown beneficial in every study from the controversial Women’s Health Initiative study in the early 2000s to the present. The benefit is seen across delivery methods (transdermals, transvaginal, or oral), even at low doses. We’ll get into delivery methods below. Given that the lifetime risk of a woman to have an osteoporotic fracture is 1 in 2 (50%), protecting bone is a high priority for most.

The risk of breast cancer is often top of mind for women considering hormone replacement therapy, and research has been conflicting. Fortunately, a new huge study which included more than half a million women, provides reassurance. “It found that – in line with other evidence – the risks of HRT are generally low. Breast cancer risks were extremely low with oestrogen-only HRT, but this can only be taken by women who have had their womb removed (hysterectomy). Most women take combined HRT which contains oestrogen and progestogen. The type of progestogen in combined HRT made a difference: norethisterone was linked to the highest increases in risk of breast cancer. (That is a synthetic progestogen, which cannot be compared apples-to-apples with bioidentical progesterone). The researchers stressed that some women who had never taken HRT would still get breast cancer. For example, if a group of 10,000 women in their 50s had never taken HRT, 26 women would still get breast cancer in a year. If all 10,000 women had recently taken combined HRT for less than 5 years, 35 would get breast cancer. So, in this large group of women, the HRT is linked to 9 extra cases of breast cancer in a year. That is less than one in a thousand women”. 3

Other health factors that women may need to consider to understand their personal risk/benefit ratio include their risk of other diseases. Oral HRT is associated with a small increase in stroke risk, but transdermal HRT has a largely neutral, possibly protective cardiovascular effect (improves cholesterol ratios, relaxes hypertension). Additionally, HRT protects against colorectal cancer, dementia, and of course life-disrupting symptoms such as hot flashes, vaginal atrophy, insomnia, and mood changes. 4

Fine-tuning the decision to use HRT for osteoporosis can be made by choosing the delivery method associated the lowest risk. It appears transdermal application has less risk that oral estrogens which are associated with a variety of clotting issues such as deep vein thromboses & ischemic strokes. 5 Oral estrogens also negatively impact triglyceride levels and inflammatory markers and require much higher doses to achieve symptom relief. I never prescribe oral estrogens, nor do I recommend forms that are not bio-identical. Even amongst the topical transdermal application methods, there are options. I am one of California’s only certified Menopause Method prescribers, which is a system that uses organic oil as a base for the bioidentical hormones. I prefer this option as it further reduces the risks associated with exposure to parabens, phthalates and stabilizers in the cream bases. For some women, patches or vaginal rings are an option, although these are limited to estradiol (estriol combination is not available).

While every woman must make an informed decision based on her own situation, the majority of symptomatic menopausal women will both improve their quality of life, and reduce their risk of osteoporosis, dementia, and colorectal cancer with the use of bioidentical hormone replacement therapy. Please also see my companion blog post, Optimizing Osteoporosis, which reviews the lifestyle and dietary supplements that reduce the risk of osteoporosis – there are many easy things to implement beyond just hormone replacement therapy.

1 Gosset A, Pouillès JM, Trémollieres F. Menopausal hormone therapy for the management of osteoporosis. Best Pract Res Clin Endocrinol Metab. 2021 Dec;35(6):101551. doi: 10.1016/j.beem.2021.101551. Epub 2021 Jun 2. PMID: 34119418. 2 Gregson CL, Armstrong DJ, Bowden J, Cooper C, Edwards J, Gittoes NJL, Harvey N, Kanis J, Leyland S, Low R, McCloskey E, Moss K, Parker J, Paskins Z, Poole K, Reid DM, Stone M, Thomson J, Vine N, Compston J. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. 2022 Apr 5;17(1):58. doi: 10.1007/s11657-022-01061-5. Erratum in: Arch Osteoporos. 2022 May 19;17(1):80. PMID: 35378630; PMCID: PMC8979902. 3 https://evidence.nihr.ac.uk/alert/risk-of-breast-cancer-with-hrt-depends-therapy-type-and-duration/ 4 https://my.clevelandclinic.org/health/articles/16979-estrogen–hormones 5 https://www.naturalmedicinejournal.com/journal/bioidentical-hormone-replacement-therapy-postmenopausal-osteoporosis

Severe pain during your period, bloating, and painful intercourse shouldn’t be accepted as normal. Women experiencing these symptoms could have endometriosis, a condition affecting about 10% of females of reproductive age. Despite its prevalence, endometriosis can be difficult to treat, and it often worsens over time. As a result, endometriosis can have an ongoing negative impact on a woman’s life.But it doesn’t have to be that way!

Let’s take a look at the symptoms and causes behind endometriosis and some natural ways to treat it.

What Is Endometriosis?

The endometrium is the lining of your uterus, which comes from the Greek word “endo” meaning within. When the endometrium grows outside of the uterus and spreads to other organs in the abdominal cavity like the ovaries, fallopian tubes, bladder, and rectum, it’s called endometriosis. This condition is fueled by estrogen levels and causes swelling, inflammation, and adhesions around the affected organs, essentially locking them in place.

Is Endometriosis The Reason Behind Your Pain?

The most pronounced sign of endometriosis is pain in the abdomen, often extreme and debilitating. Severely painful periods are a common symptom, but pain can also be felt in other areas, like the back, legs, and rectum.

Other physical symptoms include:

• Painful bowel movements

• Pain during intercourse

• Diarrhea

• Constipation

• Heavy periods

• Nausea

• Fatigue

The pain from endometriosis is different from regular menstrual cramps. It’s often chronic, occurring at all times of the month, and regular pain relievers for cramps don’t have much of an impact.

Not surprisingly given the pain experienced, it can also have a large impact on a woman’s mental health. Many women with endometriosis also experience anxiety and depression. Insomnia is also common.

Endometriosis can also impact fertility. One study found that as many as 50% of women seeking treatment for infertility have endometriosis!

Say Goodbye To Pain And Discomfort From Endometriosis

A healthy lifestyle that aims to reduce inflammation is the best approach to ending endometriosis. Be sure to include the following in your daily routine.

1 – Eat an anti-inflammatory diet

• Prioritize whole foods. To reduce inflammation, choose whole foods, particularly foods high in antioxidants, like brightly colored veggies, and omega-3 fatty acids, found in fish, nuts, and eggs. Avoid overly processed foods.

• Eat organic. Some research shows that pesticides and artificial colorings can contribute to endometriosis.

• Go gluten free. Studies show many women’s symptoms improved after eliminating gluten.

• Avoid red meat. Red meat is linked to the development of endometriosis. Women who replace red meat with fish experience fewer symptoms.

• Use caution with dairy. A few studies show that dairy consumption actually reduces the risk of endometriosis, but some women do report it worsens their symptoms. Keep a food diary to see how dairy consumption affects you. If you do eat dairy, choose organic products whenever possible.

• Drink ginger or green tea. If you experience nausea, some warm ginger tea will bring relief. Green tea has antioxidant properties to help with inflammation.

• Focus on fiber. Your body eliminates excess estrogen in your stool, so boosting your fiber content is a good idea.It can also help with any constipation triggered by endometriosis.

• Avoid alcohol. Alcohol is inflammatory and many women report it makes their symptoms worse.

2 – Exercise has so many benefits!

Exercise has been found to be an effective natural way of managing pain and inflammation associated with endometriosis. While it might seem counterintuitive to engage in physical activity while experiencing pelvic pain, low-impact exercises like walking, yoga, and swimming can help reduce inflammation and ease discomfort.

Exercise stimulates the production of endorphins, which are natural painkillers that can alleviate the severity of menstrual cramps and pain caused by endometriosis. Furthermore, regular exercise can help improve blood flow to the pelvic area, which can reduce inflammation and help the body flush out toxins. Incorporating gentle exercise into your routine can provide a significant relief for endometriosis symptoms, although it’s important to consult your doctor before starting any new exercise regimen.

3 – Talk to us about supplements that can help

Some supplements that treat endometriosis include:

• Bromelain. This enzyme, found in pineapple, can relieve symptoms.

• Turmeric. An anti-inflammatory spice also available in supplement form.

• DIM or diindolylmethane is a compound created when you eat cruciferous vegetables. It can improve the way estrogen receptors react to estrogen.

• NAC or N-acetylcysteine can slow the growth of endometrial cells.

We can work together to create a supplement regime that matches your health profile. It’s always important to work with a professional, since some supplements can interact or may not be suited for your unique needs.

4 – Try your best to reduce stress.

The pain associated with endometriosis can take a large toll on women’s health. It’s important to prioritize self-care. And, by building a relaxation routine, you could even slow the growth of endometriosis.

Living with endometriosis is stressful. Chronic stress worsens inflammatory conditions like endometriosis. It also disrupts hormonal balance and can lead to estrogen dominance. The end result is often a cycle of worsening symptoms.

Mindful meditation, yoga, and moderate exercise can help manage your body’s reaction to stress. Take the time for relaxing activities like warm baths and massages. Cognitive therapy can also help you develop strategies for coping.

We’re here to help you treat endometriosis the natural way so you don’t have to deal with the pain and other symptoms. Reach out today to get started.

SOURCES

World Health Organization, “Endometriosis”

https://www.who.int/news-room/fact-sheets/detail/endometriosis

Warzecha D, Szymusik I, Wielgos M, Pietrzak B. The Impact of Endometriosis on the Quality of Life and the Incidence of Depression-A Cohort Study. Int J Environ Res Public Health. 2020 May 21;17(10):3641. doi: 10.3390/ijerph17103641. PMID: 32455821; PMCID: PMC7277332.

Ball E, Khan KS. Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Res. 2020 Feb 4;9:F1000 Faculty Rev-83. doi: 10.12688/f1000research.20750.1. PMID: 32089831; PMCID: PMC7001750

Buggio L, Barbara G, Facchin F, Frattaruolo MP, Aimi G, Berlanda N. Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care. Int J Womens Health. 2017;9:281-293

https://doi.org/10.2147/IJWH.S119724

Qi X, Zhang W, Ge M, Sun Q, Peng L, Cheng W, Li X. Relationship Between Dairy Products Intake and Risk of Endometriosis: A Systematic Review and Dose-Response Meta-Analysis. Front Nutr. 2021 Jul 22;8:701860. doi: 10.3389/fnut.2021.701860. PMID: 34368211; PMCID: PMC8339299.

Li Piani, L., Chiaffarino, F., Cipriani, S. et al. A systematic review and meta-analysis on alcohol consumption and risk of endometriosis: an update from 2012. Sci Rep 12, 19122 (2022). https://doi.org/10.1038/s41598-022-21173-9

A Qualitative Study on the Practice of Yoga for Women with Pain-Associated Endometriosis, Andrea Vasconcelos Gonçalves, Maria Y. Makuch, Maria Silvia Setubal, Nelson Filice Barros, and Luis Bahamondes Published Online: 1 Dec 2016 https://doi.org/10.1089/acm.2016.0021

Lete I, Mendoza N, de la Viuda E, Carmona F. Effectiveness of an antioxidant preparation with N-acetyl cysteine, alpha lipoic acid and bromelain in the treatment of endometriosis-associated pelvic pain: LEAP study. Eur J Obstet Gynecol Reprod Biol. 2018 Sep;228:221-224. doi: 10.1016/j.ejogrb.2018.07.002. Epub 2018 Jul 6. PMID: 30007250.

Morales-Prieto DM, Herrmann J, Osterwald H, Kochhar PS, Schleussner E, Markert UR, Oettel M. Comparison of dienogest effects upon 3,3′-diindolylmethane supplementation in models of endometriosis and clinical cases. Reprod Biol. 2018 Sep;18(3):252-258. doi: 10.1016/j.repbio.2018.07.002. Epub 2018 Jul 9. PMID: 30001982.

Cuevas M, Cruz ML, Ramirez AE, Flores I, Thompson KJ, Bayona M, Vernon MW, Appleyard CB. Stress During Development of Experimental Endometriosis Influences Nerve Growth and Disease Progression. Reprod Sci. 2018 Mar;25(3):347-357. doi: 10.1177/1933719117737846. Epub 2017 Nov 6. PMID: 29108503; PMCID: PMC6343219.

Introduction Menopause is a natural phase in a woman’s life, but it often comes with a variety of challenging symptoms, such as hot flashes, mood swings, and sleep disturbances. Bioidentical Hormone Replacement Therapy (BHRT) is one option that has gained popularity in recent years for managing these symptoms. In this blog post, we’ll review the benefits and risks of BHRT, the different forms of hormones, and the importance of safely monitoring hormone use based on the July 2023 American Family Physician’s article on “Managing Menopausal Symptoms.”

What is Bioidentical Hormone Replacement Therapy BHRT means using hormones that are molecularly identical to the forms we naturally make in our ovaries before menopause. This is in comparison to conventional hormone replacement therapy that used conjugated equine estrogens that are molecularly identical to pregnant horse hormones and progestin, which is a synthetic but binds somewhat effectively in our naturally occurring progesterone receptors. The bioidentical hormones are estradiol, estriol, progesterone, DHEA and testosterone.

Benefits of Bioidentical Hormone Replacement Therapy BHRT involves the use of hormones that are structurally identical to those produced naturally by the body. This fundamental similarity makes BHRT an appealing option for many women experiencing menopausal symptoms. Some of the potential benefits of BHRT include: 1. Relief from Hot Flashes and Night Sweats: Bioidentical hormones can effectively alleviate these bothersome symptoms, improving sleep and overall comfort. 2. Mood Stabilization: BHRT may help regulate mood swings and reduce irritability, anxiety, and sleep disorders commonly associated with menopause. 3. Bone Health: Hormone therapy can help maintain bone density and reduce the risk of osteoporosis. 4. Improved Vaginal Health: BHRT can alleviate vaginal dryness and discomfort, making sexual intercourse more enjoyable. It also protects against urinary incontinence and overall genitourinary symptoms. Libido often improves as well.

5. Enhanced Cognitive Function: Some studies suggest that BHRT may have a positive impact on cognitive function and memory. 6. Enhanced Vitality: BHRT users report higher quality of life, feeling younger and stronger, and enjoying overall anti-aging benefits. 7. Improved Skin Integrity, collagen production, and facial tone and prevention of muscle laxity. 8. Prevention of chronic diseases including diabetes, colorectal cancer, and cardiovascular disease. In fact, all-cause mortality is lower among women using BHRT, and premature menopause/hypogonadism is a known risk factor for early mortality due to the increase risk women with low lifetime hormone exposure have of these conditions, as well as frailty, and fractures.

Risks of Bioidentical Hormone Replacement Therapy While BHRT offers many potential benefits, it’s essential to consider the associated risks and limitations: 1. Blood Clot Risk: Hormone therapy may elevate the risk of blood clots, thromboembolism, which can lead to serious health complications. 2. Increased Risk of Gall Bladder Disease: It’s unclear why, and there are many ways to improve and manage gall bladder health with diet and lifestyle strategies. 3. Uterine Cancer Risk: Women who have not had a hysterectomy and take estrogen without progesterone may face an increased risk of uterine cancer. 4. Increased Risk of Breast Cancer: Hormone replacement therapy has been linked to a slightly increased risk of breast cancer, although the extent of this risk remains a subject of debate. A recent review of 25 clinical trials that looked for associations between breast cancer and hormone replacement therapy found that only 1 of those 25 trials found an increased rate of breast cancer recurrence in women who had previously had breast cancer and used HRT. The subgroup analysis demonstrated that this was true for women with hormone receptor positive (HR+) cancers, but not for HR- ones Another trial has shown a lower rate of breast cancer among women taking estrogen-only HRT (women who have had hysterectomies and don’t need progesterone for endometrial protection). (references at the end of this blog). It is also important to put the degree of risk in context with other risk factors. For example, obesity incurs a 60% increased risk of breast cancer which is much greater than BHRT.

5. Individual Variability: The effectiveness and safety of BHRT can vary from person to person, making personalized treatment plans crucial.

Forms of Bioidentical Hormones Bioidentical hormones can be administered in several forms, tailored to individual preferences and needs. These forms include: 1. Oral: Pills or capsules are a common method, but suboptimal option. Because of gastric metabolism, taking hormones orally requires very high doses to get a small percentage of what is taken into circulation. Further, the liver has to process and detoxify all the excess and some of the metabolites created by the liver are considered more toxic and higher risk than estradiol alone. I rarely use oral estradiol for these reasons. While the same holds true for progesterone, some of the metabolites of progesterone are actually beneficial for improved sleep and relaxation. 2. Transdermal: Patches, gels, creams, and oils, applied to the skin offer a steady release of hormones into the bloodstream. Transdermals are the best method to allow for fine-tuning of doses by the prescriber and patient. And because we can control the base cream, gel, or oil, we can control exposure to unwanted additives like parabens or phthalates and chemicals that are common in low-quality personal care products. There is an organic oil base that most prescribers are unfamiliar with. If you care about chemical exposures, this option is the cleanest one available. 3. Pellets: Tiny hormone pellets implanted under the skin release hormones gradually over several months. Convenient, but if the dose isn’t right, there’s no way to take them out! 4. Injections: Intramuscular or subcutaneous injections provide rapid delivery of hormones but require weekly appointments.

Monitoring Hormone Use Monitoring BHRT is crucial for ensuring safety and efficacy. This involves regular check-ups and various tests, including: 1. Lab Testing: Hormone levels should be regularly assessed to ensure they are within the desired range, not excessively high, and that hormone metabolites are being appropriately processed and metabolized. Blood tests can only give a glimpse of circulating hormone levels at the moment of testing. Urinary hormone testing is superior and is the only way to accurately measure metabolites. Read more in the references at the bottom. 2. Mammograms: Regular breast cancer screening through mammograms is vital for early detection and treatment. In March of 2023, guidelines for reporting mammograms changed and now comment on the density of the tissue. Dense tissue can obscure small masses and may also increase the risk of breast cancer. If you have dense breasts, it is probably wise to use a

more sensitive method of screening. While there is no consensus on this, 3D mammography (digital breast tomosyntesis), ultrasounds, and MRIs can show things that are not visible on mammogram. But those may not be covered by insurance. 3. Pelvic Ultrasounds: If unusual bleeding or spotting occurs, a pelvic ultrasound can help identify any abnormalities in the uterine or ovarian tissues. 4. Hormone Metabolite Testing: Tests such as the DUTCH urinary hormone panel or similar panels provide a comprehensive view of hormone metabolites. This data helps understand how well the body is metabolizing or processing the hormones, aiding in treatment adjustments.

Non-hormonal Strategies for Menopausal Symptoms There are other options beside BHRT for women who for whatever reason prefer to try non- hormonal methods to manage symptoms and address prevention and healthy aging. In fact, in most of my patients, I employee some of these strategies along with BHRT. For vasomotor symptoms, some women find relief with high dose vitamin E and soy isoflavones. Isoflavones are particularly useful because they also reduce the risk of cardiovascular disease, breast & uterine cancer, dementia, osteoporosis, and many of the same conditions we seek to address with BHRT. Urogenital symptoms often respond to non-hormonal therapies like hyaluronic acid and homeopathic suppositories that can moisturize vaginal tissue and maintain pH balance. For more information on lifestyle factors, see my previous blog post on Hormone Harmony (link below).

Conclusion Bioidentical Hormone Replacement Therapy can be a valuable tool in managing menopausal symptoms and planning for a healthy, vital second half of a woman’s life, but it is essential to weigh the benefits and risks carefully and tailor treatment to individual needs. Regular monitoring, using methods like hormone level testing and advanced metabolite analysis, ensures the safety and efficacy of BHRT. Choosing the right dose and right delivery method are also critical. As one of California’s only doctors certified by the Institute of Bioidentical Medicine and Dr. Rosensweet’s Menopause Method, you will find no one more experienced in BHRT than Dr. Oberg. If you are curious of hormones might provide relief from menopausal symptoms and enhance your quality of life during this significant life transition, consider scheduling a complimentary 15 minute exploratory call with Dr. Oberg to see if working with her would be a good fit.

References:

1. AAFP menopause management: https://www.aafp.org/pubs/afp/issues/2023/0700/menopausal-symptoms.html

2. Soy isoflavones: https://pubmed.ncbi.nlm.nih.gov/33809928/

3. HRT in breast cancer survivors: https://pubmed.ncbi.nlm.nih.gov/34731351/ 1. https://pubmed.ncbi.nlm.nih.gov/35594465/ 2. https://pubmed.ncbi.nlm.nih.gov/35854422/

4. HRT and all-cause mortality/CVD: https://pubmed.ncbi.nlm.nih.gov/35594469/

5. Mammography guidelines: https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/mammograms/breast-density-and-your-mammogram-report.html

6. BHRT and osteoporosis blog: hormones-osteoporosis-are-bioidentical-hormones-right-for-me

7. Hormone Harmony blog: hormone-balance